18 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
Time to bust common osteoarthritis myths
Senior Lecturer, Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Senior Lecturer, School of Physiotherapy, University of Otago, Dunedin, New Zealand
Post-Doctoral Fellow, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Head of School, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
Several common beliefs about osteoarthritis held by people living with the condition and some clinicians are discordant with
current evidence and can hinder effective management. Therefore, providing information about the disease and its mechanisms
could lead to better management of people with osteoarthritis. This paper addresses the seven most common myths surrounding
osteoarthritis relating to its causative factors, pathology, assessment and management. We present the evidence to refute these
misconceptions and argue that physiotherapists are in an ideal position to provide education to people with osteoarthritis. Ultimately,
physiotherapists can play a central role in the provision of care for people with osteoarthritis.
O’Brien, D. W., Chapple, C. M., Baldwin, J. N., & Larmer, P. J. (2019). Time to bust common osteoarthritis myths. New
Zealand Journal of Physiotherapy, 47(1), 18-24. https://doi.org/10.15619/NZJP/47.1.03
Key Words: Osteoarthritis, Beliefs, Attitudes, Treatment, Misconceptions
Osteoarthritis is the most common form of arthritis and,
typically, affects the joints of the knees, hips, spine and hands
(Hochberg, Silman, Smolen, Weinblatt, & Weisman, 2015;
Palazzo, Nguyen, Lefevre-Colau, Rannou, & Poiraudeau, 2016).
People with osteoarthritis often experience pain, joint stiffness
and weakness; this can affect their mobility, function, ability to
work, mental well-being and independence (Hall et al., 2008;
Hawker et al., 2010, 2011). Approximately 670,000 New
Zealanders live with some form of arthritis, of which 56% of
these people have osteoarthritis. Furthermore, prevalence is
expected to reach 1 million by 2040 due to projected increases
in the age of the population and the growing obesity rate,
factors known to affect the development of osteoarthritis
(Access Economics, 2018; Cross et al., 2014; Palazzo et al.,
2016). The total estimated cost of arthritis in New Zealand is
$12.2 billion per year, including $993 million in health sector
costs, $1.2 billion in lost productivity and $1.6 billion in formal
and informal care (Access Economics, 2018).
There is currently no cure for osteoarthritis, and unlike other
forms of arthritis, there are no disease-modifying drugs with
proven efcacy available for the condition. The focus of recent
research has been on the maintenance of physical function,
symptom reduction and limiting disease progression (Hochberg
et al., 2015). Exhausting all conservative treatment options is
encouraged before more invasive interventions are employed
(Hunter, 2017; Van Manen, Nace, & Mont, 2012; Zhang et al.,
2008). Current clinical guidelines recommend the use of non-
pharmacological treatments, such as lifestyle change, weight
loss, exercise and manual therapy (non-pharmacological), before
considering medication or surgery (Bennell, 2013; Bennell &
Hinman, 2011; Dean & Gormsen Hansen, 2012; Fransen et
al., 2015; Merashly & Uthman, 2012; Van Manen et al., 2012;
Zhang et al., 2008). The National Institute for Health and Care
Excellence (NICE) Osteoarthritis Guidelines (2014) advocate for a
staged progressive model of clinical management, which shows
a progression from non-pharmacological to pharmacological
to surgical management of osteoarthritis. However, non-
pharmacological treatments are underutilised, and while failed
conservative management is a prerequisite for surgery, some
people are offered joint replacement surgery without having
completed appropriate conservative management (Brand et
al., 2014; Hunter, 2011; Hunter & Lo, 2009). The continued
focus by some clinicians on the provision of pharmaceutical and
surgical treatment options has prompted some researchers to
publish editorials arguing that most people with hip and knee
osteoarthritis in high-income countries receive substandard
care (Hunter, 2011, 2017; Hunter & Lo, 2009; Hunter, Neogi,
& Hochberg, 2011). Additionally, it has been suggested that
some clinicians are guilty of benign neglect because they take
a fatalistic view of osteoarthritis or see conservative treatment
as ineffective or too complicated for their patients (Brand et al.,
2014; Poitras et al., 2010).
Despite the considerable amount of research detailing best
practice management for osteoarthritis, many high-income
countries, including New Zealand, have been slow to adopt
these recommendations (Baldwin, Briggs, Bagg, & Larmer, 2017;
Bennell, Dobson, & Hinman, 2014; Hunter, 2017). This delay
has been attributed, in part, to some of the common myths
about the disease (Hunter, 2017). In particular, myths about
causative factors, the pathology, assessment and management
NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 19
of osteoarthritis abound. This paper aims to challenge the
myths commonly attributed to osteoarthritis that limit effective
treatment; outline best clinical practice; and encourage
physiotherapists to engage with people with osteoarthritis.
MYTHS COMMONLY ATTRIBUTED TO OSTEOARTHRITIS
Myth 1: Osteoarthritis is just an old person’s disease
It is true that the likelihood of having osteoarthritis increases
with age, but it is incorrect to claim that it is an “old person’s
disease” as hip and knee osteoarthritis can also affect younger
people (Ackerman, Kemp, Crossley, Culvenor, & Hinman, 2017).
Ackerman et al. (2015) demonstrated the considerable personal
burden experienced by younger people (20 to 55 years) with
lower limb osteoarthritis, and recommended the provision of
targeted services for people in this age group. Furthermore,
younger aged people warrant additional attention to reduce the
development of comorbidities which may further compromise
their well-being (Skou, Pedersen, Abbott, Patterson, & Barton,
2018). Hence, it is false to solely attribute the development of
the disease to increasing age as its aetiology is multi-factorial
(Hochberg et al., 2015). The exact association between
osteoarthritis and increasing age is complex and not currently
fully comprehended (Hochberg et al., 2015). Increasing age
can lead to thinning and fracture of the cartilage covering the
articular surfaces of the joints. These changes can result in joint
laxity, predisposing the joint to increased shear stresses and
injury, promoting progression of the disease (Cross et al., 2014;
Hochberg et al., 2015).
However, many factors other than age are associated with
an increased chance of developing osteoarthritis. These
include gender, obesity, genetics, joint structure, a history of
injury and occupation (Palazzo et al., 2016). Osteoarthritis is
characteristically more prevalent in women than men, with
an odds ratio of 1.6 (95% condence interval [CI] 1.4-2.1)
(Silverwood et al., 2015). The reason for this is linked to
differences in hormones, joint alignment, cartilage volume
and muscle strength (Cross et al., 2014). People who are
obese are 2.7 times more likely (95% CI 2.2-3.3) to have knee
osteoarthritis than people who are not obese (Silverwood et al.,
2015). Increased body weight is believed to cause additional
joint loading and damage (Bliddal, Leeds, & Christensen, 2014)
as well as to contribute to systemic inammation (Piva et al.,
2015). Previous hip or knee joint injury is strongly associated
with the development of osteoarthritis (Hochberg et al., 2015).
Rupture of the anterior cruciate ligament predictably leads
to the development of knee osteoarthritis in 13% of people
within 10 to 15 years of the injury, and this rate increases
to between 20 and 40% if the injury also includes damage
to other ligaments, bone or cartilage (Palazzo et al., 2016).
Poor joint alignment is associated with the development of
osteoarthritis and more strongly associated with progression
of the disease (Cerejo et al., 2002; Sharma et al., 2010). In the
hip, joint dysplasia can commonly lead to the early development
of osteoarthritic changes (Jacobsen & Sonne-Holm, 2005).
Additionally, excessive occupational loads have been linked
to increased risk of disease development, especially if the job
or occupation requires a lot of kneeling, squatting, lifting or
climbing (Palmer, 2012).
Practice point myth 1: Osteoarthritis can affect younger people
and should be considered as a provisional diagnosis where there
are appropriate signs and symptoms.
Myth 2: Osteoarthritis is just joint wear and tear
Osteoarthritis is commonly typied by structural cartilage
changes. However, there are also changes in the muscles,
bone and synovial tissue at the joint. Hence, it may be best to
conceptualise osteoarthritis as a syndrome or a collection of
signs and symptoms. The pathology of osteoarthritis is multi-
faceted, and many different factors contribute to the joint
degeneration that occurs (Dell’Isola, Allan, Smith, Marreiros,
& Steultjens, 2016). These include biomechanical overload,
structural changes of the cartilage, metabolic mechanisms,
inammatory processes and genetic traits. While mechanical
factors are known to be necessary for the development of
osteoarthritis, it is still unclear what role the other factors
play (Hochberg et al., 2015). Osteoarthritis is known to be a
metabolically active disease, and changes can also occur within
the peripheral and central nervous systems, which may explain
non-mechanical pain symptoms described by some people with
osteoarthritis (Cruz-Almeida et al., 2013; Mease, Hanna, Frakes,
& Altman, 2011; Mills, Hübscher, O’Leary, & Moloney, 2019;
Skou et al., 2018).
In contrast to the notion that the joint is wearing out,
moderate levels of physical activity and exercise are believed
to be protective against the development of hip and knee
osteoarthritis (Bennell & Hinman, 2011; Fransen et al., 2015;
Skou et al., 2018). Normally functioning muscles have a
protective effect on joints as they distribute load across the
joint and help to maintain postural alignment (Bennell, Wrigley,
Hunt, Lim, & Hinman, 2013). Furthermore, there is a plethora
of studies demonstrating that improving muscle function with
exercise can reduce pain and improve function for people with
hip and knee osteoarthritis (Fransen et al., 2015; Hochberg et
al., 2012; Hunter & Lo, 2009; Loew et al., 2012; Skou et al.,
2018). Conversely, weak muscles at or around joints can lead
to the development of osteoarthritis due to a higher chance of
injury and altered load management (Hochberg et al., 2015).
Practice point myth 2: Osteoarthritis is not “just” joint wear and
tear. The disease is better conceptualised as a syndrome that
includes joint wear and failed repair. Hence, it is essential to
avoid describing or referring to osteoarthritis as “wear and tear”
when speaking with patients.
Myth 3: The worse the imaging looks, the worse the
Imaging, such as radiographs and magnetic resonance imaging
(MRI), is a standard tool used to diagnose osteoarthritis.
However, only half of the people with radiographic osteoarthritis
(visible x-ray changes) have clinical symptoms (Jordan et al.,
2007; Phan et al., 2005). As such, the assessment of a person’s
signs and symptoms may be more clinically relevant than the
imaging ndings. Furthermore, clinical guidelines suggest that
requesting an x-ray is not required to make the diagnosis of
osteoarthritis and is potentially problematic as it reinforces a
mechanical view of the disease (Bennell, 2013; Hunter, 2017;
McAlindon et al., 2014; National Institute for Health and Care
Excellence, 2015). In most cases, the diagnosis of hip or knee
20 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
joint osteoarthritis can be made by considering the signs and
symptoms that a person presents with (Hochberg et al., 2015).
Imaging should only be considered when appraising a person’s
appropriateness for surgery or when ruling out other potential
Practice point myth 3: Consider the additional merit of imaging
carefully. Radiographic changes can correlate poorly with
symptoms and lead to unnecessary interventions. Take care
when describing imaging ndings to people with osteoarthritis.
For example, avoid using terminology such as “degeneration”
or “bone on bone” that may incite fear-avoidance behaviours or
the belief that nothing can be done to manage the symptoms of
Myth 4: Osteoarthritis is the non-inammatory arthritis
Osteoarthritis was traditionally considered to be non-
inammatory arthritis, but the presence of inammatory
processes are now acknowledged (Berenbaum, 2013). Synovial
tissue inammation is believed to be one of the key intraarticular
processes that contributes to nociception and the subsequent
pain experience, with the inammatory changes leading to
intraarticular swelling (Felson et al., 2016). Moreover, extra-
articular structures can also become inamed and contribute
to the generation of nociceptive input (Hochberg et al., 2015).
Low-grade chronic inammation may be a consequence of
knee injury, or induced by metabolic syndrome or inammaging
(age-associated inammation), all of which are known risk
factors for the development of knee osteoarthritis (Berenbaum,
2013). Recent research has suggested a relationship between
osteoarthritis and metabolic disorders (Da Costa et al.,
2012; Mills et al., 2019). While the exact link is not yet fully
understood, a high body mass index and cardiometabolic
disease are associated with systemic inammation, and it
is this systemic inammation which is thought to inuence
osteoarthritis (Mills et al., 2019). Some researchers have argued
that metabolic-osteoarthritis should be described as a distinct
category or phenotype of osteoarthritis (Dell’Isola et al., 2016;
Deveza et al., 2017). Of note is that exercise is known to reduce
systemic inammation, which may explain why physical activity
positively affects pain and function for people with osteoarthritis
(Skou et al., 2018).
Practice point myth 4: Exercise can be benecial in reducing
inammation for people with osteoarthritis, and physiotherapists
can play a key role in prescribing exercise programmes.
Additionally, physiotherapists should consider engaging the
patient’s general practitioner for an analgesic review when
medication is considered appropriate.
Myth 5: Conservative treatments are ineffectual and only
designed to delay joint replacement surgery
Education, lifestyle and dietary changes, and exercise are the
cornerstone of management for people with osteoarthritis
(Bennell, 2013; Fransen et al., 2015; Hochberg et al., 2015;
Hunter & Lo, 2009). The focus of treatment for a person
with osteoarthritis should be on the maintenance of physical
function, modication of symptoms and limiting disease
progression (Fransen et al., 2015; Hochberg et al., 2015).
Treatment options should be employed progressively, starting
with more conservative treatments (exercise, weight loss,
education), and then progressing to pharmacological and more
invasive interventions (medication, surgery) as needed, while
incorporating patient preferences (Fransen et al., 2015; Larmer,
Reay, Aubert, & Kersten, 2014; National Institue for Health
and Care Excellence, 2015). In particular, there is abundant
high-quality evidence supporting exercise-based treatments
for people with hip and knee osteoarthritis (Bennell & Hinman,
2011; Fransen et al., 2015). Research shows that exercise
can positively inuence pain, muscle function, body weight,
cardiovascular tness, mood and disease progression (Bartholdy
et al., 2017; Bennell et al., 2014; Fransen et al., 2015; Kujala,
2009; Zhang et al., 2008), regardless of the structural changes
and symptom severity. The addition of joint mobilisation and
manipulation to exercise programmes may also be benecial
(Fitzgerald et al., 2016; Pinto et al., 2013).
Two of the biggest limitations to the efcacy of exercise-based
treatment are prescription and patient adherence. Poor exercise
prescription for people with knee osteoarthritis can result in
either overloading the affected joint, leading to increases in
pain and swelling; or more commonly, prescribed exercises
that are not challenging enough to facilitate a training effect
(Brosseau et al., 2016; Fransen et al., 2015; Hunter, 2017).
The inclusion of strategies to improve the adherence to the
prescribed exercises could boost treatment effectiveness (Bennell
et al., 2014; O’Brien, Bassett, & McNair, 2013). Physiotherapists
should consider employing strategies that assist people to begin
and sustain new behaviours that improve their osteoarthritis
(Bassett, 2015). Furthermore, as osteoarthritis is a chronic
disease, treatment should be viewed as a continuum of care;
hence, booster sessions should be considered to assist in the
maintenance of regular exercise (Brand, Ackerman, Bohensky, &
Bennell, 2013; Rosemann, Laux, Szecsenyi, & Grol, 2008).
Practice points myth 5: Exercise, education and weight loss
(where appropriate) are essential interventions for all people
with osteoarthritis, regardless of disease progression or symptom
severity. Prescribed exercises or physical activity programmes
should be collaboratively designed, should challenge the patient
and promote a training response, and should incorporate
strategies to enhance adherence. Joint mobilisation may also be
benecial if clinically indicated.
Myth 6: Discussing weight loss with people with
osteoarthritis is outside my scope of practice
Increased body weight is a known risk factor for the
development of lower limb osteoarthritis, and obesity is
commonly associated with progression of the condition
(Chapple, Nicholson, Baxter, & Abbott, 2011; Jacobs,
Vranceanu, Thompson, & Lattermann, 2018; Palazzo et
al., 2016; Silverwood et al., 2015). Furthermore, obesity is
associated with more negative treatment outcomes (Bliddal et
al., 2014). Weight loss is strongly recommended for people with
obesity and osteoarthritis, not only to decrease joint loading,
but also to counteract the inammatory effects of metabolically
active tissue (Chapple et al., 2011; Cicuttini & Wluka, 2016;
Jacobs et al., 2018; Palazzo et al., 2016; Silverwood et al.,
2015). Reducing body weight can signicantly lessen a person’s
likelihood of developing osteoarthritis. Critically, a reduction of
≥10% of body weight can lead to considerable reductions in
NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 21
pain for people who already have the disease (Atukorala et al.,
2016). While some physiotherapists may believe that discussing
weight loss with a patient is outside their scope of practice,
physiotherapists are well placed to assist people with making
lifestyle changes that will contribute to weight loss.
Practice point myth 6: Obesity is a known modiable risk factor
for osteoarthritis, and physiotherapists should provide support
to people embarking on a weight loss programme or refer
them on to the appropriate health professional, e.g. dietician or
Myth 7: Joint replacement surgery is inevitable
Total joint replacement (TJR) continues to be a valid treatment
option for people with advanced hip and knee osteoarthritis, but
TJR surgery is not appropriate for everyone with osteoarthritis
(Gustafsson, Ekman, Ponzer, & Heikkilä, 2010; Gwynne-Jones,
Gray, Hutton, Stout, & Abbott, 2018; Parsons, Godfrey, & Jester,
2009). Disease progression differs from person to person, and
many people may never reach the point where TJR surgery is
appropriate or necessary. Chapple et al. (2011) identied that
disease progression is multifactorial, with predictive factors
including increasing age, varus knee alignment, radiographic
changes, high body mass index and the presence of the disease
at multiple joints. Additionally, not everyone benets from
joint replacement surgery, with a substantial portion of people
continuing to report long-term joint pain after surgery (Beswick,
Wylde, Gooberman-Hill, Blom, & Dieppe, 2012; Lingard, Katz,
Wright, & Sledge, 2004). Further research is needed to identify
people most likely to benet from surgical intervention (Rice et
Practice point myth 7: Physiotherapists should only consider
referring a person for orthopaedic review (TJR) after the patient
has failed an appropriate exercise programme that meets best
practice clinical guidelines (Brosseau et al., 2016; Fransen et al.,
WHAT DOES THE FUTURE HOLD FOR OSTEOARTHRITIS
Exercise, education and weight loss are recommended in
several clinical guidelines (Larmer et al., 2014); however these
treatment options are not consistently or routinely offered to
people with osteoarthritis in primary care (Haskins, Henderson,
& Bogduk, 2014; Hunter, 2017; Runciman et al., 2012). Within
New Zealand, the general practitioner is often the rst, and
most commonly consulted health professional for osteoarthritis
(Jolly, Bassett, O’Brien, Parkinson, & Larmer, 2017). However,
a multi-faceted approach of exercise, education and lifestyle
advice is needed to provide effective, evidence-informed care for
people with osteoarthritis. There is clearly a need for a multi-
Primary care management of osteoarthritis in New Zealand,
at present, is fragmented and episodic, and considerable
evidence-to-practice gaps exist. Calls have been made for an
osteoarthritis model of care in New Zealand, which would
provide a framework for implementing evidence-informed care
within the New Zealand primary care system (Baldwin et al.,
2017). The term “model of care” refers to an evidence-informed
framework or policy that outlines the ideal development and
delivery of principles of care within a health system. A model of
care goes one step further than clinical guidelines by not only
outlining what the care components should be, but also how to
deliver them within a particular health system (Briggs, Towler,
Speerin, & March, 2014). An osteoarthritis model of care would
incorporate chronic care principles such as multi-disciplinary
management, collaborative care planning and self-management
In Australia, experienced physiotherapists are employed as
musculoskeletal coordinators within the New South Wales
Osteoarthritis Chronic Care Program Model of Care (Briggs et
al., 2014). These musculoskeletal coordinators perform initial
assessments of people with osteoarthritis and link these patients
to relevant health professionals within the multi-disciplinary
team as well as provide overall leadership of the programme
at each site. With expertise in exercise prescription and chronic
pain management, physiotherapists are ideally positioned to
coordinate and lead person-centred care within a New Zealand
osteoarthritis model of care (Baldwin et al., 2017); upskilling
and/or extended scope of practice roles could be required. As
an example, the New Zealand government’s Mobility Action
Programme (MAP) is supporting multi-disciplinary, community-
based teams to provide early management for people with
osteoarthritis (Ministry of Health, 2018). While the MAP
represents a positive step towards optimising osteoarthritis
management in primary care, formal policy support is needed to
upscale this programme and develop an osteoarthritis model of
care that would facilitate provision of equitable care to all New
Many myths exist about osteoarthritis, and some will limit the
potential benets that people may gain from conservative
treatment. Busting these myths will lead to a better
understanding of osteoarthritis and could contribute to better
outcomes for people living with the disease. Physiotherapists
are well placed to do this through effective education of
patients and other healthcare professionals, and by leading the
implementation of best-practice care.
1. Many myths and misconceptions exist about osteoarthritis
that can have a negative impact on how it is managed and
2. As physiotherapists, we should explore osteoarthritis
beliefs of our patients to identify and clarify potential
misconceptions about the disease.
No additional funding was obtained to support the production
of this manuscript beyond the usual academic salaries of the
The authors have no conicts of interest that merit declaration.
ADDRESS FOR CORRESPONDENCE
Dr Daniel W. O’Brien, Physiotherapy Department, School of
Clinical Sciences, Auckland University of Technology, Akoranga
Drive, Northcote, Auckland. Telephone: +64 9 921 9999 ext.
8707. Email: firstname.lastname@example.org
22 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
Access Economics. (2018). The economic cost of arthritis in New Zealand
in 2018: Arthritis New Zealand. New Zealand: Delottes. Retrieved from
Ackerman, I. N., Bucknill, A., Page, R. S., Broughton, N. S., Roberts, C.,
Cavka, B., … Brand, C. A. (2015). The substantial personal burden
experienced by younger people with hip or knee osteoarthritis.
Osteoarthritis and Cartilage, 23(8), 1276–1284. https://doi.org/10.1016/j.
Ackerman, Ilana N., Kemp, J. L., Crossley, K. M., Culvenor, A., & Hinman, R.
S. (2017). Hip and knee osteoarthritis affects younger people, too. Journal
of Orthopaedic & Sports Physical Therapy, 47(2), 67–79. https://doi.
Atukorala, I., Makovey, J., Lawler, L., Messier, S. P., Bennell, K., & Hunter, D.
J. (2016). Is there a dose-response relationship between weight loss and
symptom improvement in persons with knee osteoarthritis? Arthritis Care
& Research, 68(8), 1106–1114. https://doi.org/10.1002/acr.22805
Baldwin, J., Briggs, A. M., Bagg, W., & Larmer, P. J. (2017). An osteoarthritis
model of care should be a national priority for New Zealand. New Zealand
Medical Journal, 130(1467), 78–86.
Bartholdy, C., Juhl, C., Christensen, R., Lund, H., Zhang, W., & Henriksen,
M. (2017). The role of muscle strengthening in exercise therapy for
knee osteoarthritis: A systematic review and meta-regression analysis
of randomized trials. Seminars in Arthritis and Rheumatism. https://doi.
Bassett, S. F. (2015). Bridging the intention-behaviour gap with behaviour
change strategies for physiotherapy rehabilitation non-adherence. New
Zealand Journal of Physiotherapy, 43(3), 105–111. https://doi.org/doi
Bennell, K. (2013). Physiotherapy management of hip osteoarthritis. Journal
of Physiotherapy, 59(3), 145–157. https://doi.org/10.1016/S1836-
Bennell, K. L., Dobson, F., & Hinman, R. S. (2014). Exercise in osteoarthritis:
Moving from prescription to adherence. Best Practice & Research Clinical
Rheumatology, 28(1), 93–117. https://doi.org/10.1016/j.berh.2014.01.009
Bennell, K. L., & Hinman, R. S. (2011). A review of the clinical evidence for
exercise in osteoarthritis of the hip and knee. Journal of Science and
Medicine in Sport, 14(1), 4–9. https://doi.org/10.1016/j.jsams.2010.08.002
Bennell, K. L., Wrigley, T. V., Hunt, M. A., Lim, B.-W., & Hinman, R. S. (2013).
Update on the role of muscle in the genesis and management of knee
osteoarthritis. Rheumatic Diseases Clinics of North America, 39(1), 145–
Berenbaum, F. (2013). Osteoarthritis as an inammatory disease
(osteoarthritis is not osteoarthrosis!). Osteoarthritis and Cartilage, 21(1),
Beswick, A. D., Wylde, V., Gooberman-Hill, R., Blom, A., & Dieppe, P. (2012).
What proportion of patients report long-term pain after total hip or knee
replacement for osteoarthritis? A systematic review of prospective studies
in unselected patients. BMJ Open, 2(1), e000435. https://doi.org/10.1136/
Bliddal, H., Leeds, A. R., & Christensen, R. (2014). Osteoarthritis, obesity
and weight loss: evidence, hypotheses and horizons – a scoping review.
Obesity Reviews, 15(7), 578–586. https://doi.org/10.1111/obr.12173
Brand, C., Ackerman, I. N., Bohensky, M. A., & Bennell, K. L. (2013). Chronic
disease management: A review of current performance across quality
of care domains and opportunities for improving osteoarthritis care.
Rheumatic Disease Clinics of North America, 39(1), 123–143. https://doi.
Brand, C., Harrison, C., Tropea, J., Hinman, R. S., Britt, H., & Bennell, K.
(2014). Management of osteoarthritis in general practice in Australia.
Arthritis Care & Research, 66(4), 551–558. https://doi.org/10.1002/
Briggs, A. M., Towler, S. C. B., Speerin, R., & March, L. M. (2014). Models of
care for musculoskeletal health in Australia: now more than ever to drive
evidence into health policy and practice. Australian Health Review, 38(4),
Brosseau, L., Wells, G. A., Pugh, A. G., Smith, C. A., Rahman, P., Àlvarez
Gallardo, I. C., … Longchamp, G. (2016). Ottawa Panel evidence-based
clinical practice guidelines for therapeutic exercise in the management
of hip osteoarthritis. Clinical Rehabilitation, 30(10), 935–946. https://doi.
Cerejo, R., Dunlop, D. D., Cahue, S., Channin, D., Song, J., & Sharma,
L. (2002). The inuence of alignment on risk of knee osteoarthritis
progression according to baseline stage of disease. Arthritis and
Rheumatism, 46(10), 2632–2636. https://doi.org/10.1002/art.10530
Chapple, C. M., Nicholson, H., Baxter, G. D., & Abbott, J. H. (2011). Patient
characteristics that predict progression of knee osteoarthritis: a systematic
review of prognostic studies. Arthritis Care & Research, 63(8), 1115–1125.
Cicuttini, F. M., & Wluka, A. E. (2016). Not just loading and age: the
dynamics of osteoarthritis, obesity and inammation. The Medical Journal
of Australia, 204(2), 47. https://doi.org/10.5694/mja15.01069
Cross, M., Smith, E., Hoy, D., Nolte, S., Ackerman, I., Fransen, M., …
March, L. (2014). The global burden of hip and knee osteoarthritis:
estimates from the global burden of disease 2010 study. Annals of
the Rheumatic Diseases, 73(7), 1323–1330. https://doi.org/10.1136/
Cruz-Almeida, Y., King, C. D., Goodin, B. R., Sibille, K. T., Glover, T. L., Riley, J.
L., … Fillingim, R. B. (2013). Psychological proles and pain characteristics
of older adults with knee osteoarthritis. Arthritis Care & Research, 65(11),
Da Costa, L. A., Arora, P., García-Bailo, B., Karmali, M., El-Sohemy, A., &
Badawi, A. (2012). The association between obesity, cardiometabolic
disease biomarkers, and innate immunity-related inammation in
Canadian adults. Diabetes, Metabolic Syndrome and Obesity: Targets and
Therapy, 5, 347–355. https://doi.org/10.2147/DMSO.S35115
Dean, E., & Gormsen Hansen, R. (2012). Prescribing optimal nutrition and
physical activity as rst-line interventions for best practice management of
chronic low-grade inammation associated with osteoarthritis: Evidence
synthesis. Arthritis, 2012, e560634. https://doi.org/10.1155/2012/560634
Dell’Isola, A., Allan, R., Smith, S. L., Marreiros, S. S. P., & Steultjens, M.
(2016). Identication of clinical phenotypes in knee osteoarthritis: A
systematic review of the literature. BMC Musculoskeletal Disorders, 17,
Deveza, L. A., Melo, L., Yamato, T. P., Mills, K., Ravi, V., & Hunter, D. J.
(2017). Knee osteoarthritis phenotypes and their relevance for outcomes:
A systematic review. Osteoarthritis and Cartilage. https://doi.org/10.1016/j.
Felson, D. T., Niu, J., Neogi, T., Goggins, J., Nevitt, M. C., Roemer, F.,
… MOST Investigators Group. (2016). Synovitis and the risk of knee
osteoarthritis: the MOST Study. Osteoarthritis and Cartilage, 24(3), 458–
Fitzgerald, G. K., Fritz, J. M., Childs, J. D., Brennan, G. P., Talisa, V., Gil, A.,
… Abbott, J. H. (2016). Exercise, manual therapy, and use of booster
sessions in physical therapy for knee osteoarthritis: A multi-center,
factorial randomized clinical trial. Osteoarthritis and Cartilage. https://doi.
Fransen, M., McConnell, S., Harmer, A. R., Van der Esch, M., Simic, M.,
& Bennell, K. L. (2015). Exercise for osteoarthritis of the knee. The
Cochrane Database of Systematic Reviews, 1, CD004376. https://doi.
Gustafsson, B. Å., Ekman, S.-L., Ponzer, S., & Heikkilä, K. (2010). The hip and
knee replacement operation: an extensive life event. Scandinavian Journal
of Caring Sciences, 24(4), 663–670. https://doi.org/10.1111/j.1471-
NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 23
Gwynne-Jones, D. P., Gray, A. R., Hutton, L. R., Stout, K. M., & Abbott, J. H.
(2018). Outcomes and factors inuencing response to an individualized
multidisciplinary chronic disease management program for hip and knee
osteoarthritis. The Journal of Arthroplasty. https://doi.org/10.1016/j.
Hall, M., Migay, A.-M., Persad, T., Smith, J., Yoshida, K., Kennedy, D., &
Pagura, S. (2008). Individuals’ experience of living with osteoarthritis of the
knee and perceptions of total knee arthroplasty. Physiotherapy Theory and
Practice, 24(3), 167–181. https://doi.org/10.1080/09593980701588326
Haskins, R., Henderson, J. M., & Bogduk, N. (2014). Health professional
consultation and use of conservative management strategies in patients
with knee or hip osteoarthritis awaiting orthopaedic consultation.
Australian Journal of Primary Health, 20(3), 305–310. https://doi.
Hawker, G., French, M. R., Waugh, E. J., Gignac, M. a. M., Cheung, C.,
& Murray, B. J. (2010). The multidimensionality of sleep quality and
its relationship to fatigue in older adults with painful osteoarthritis.
Osteoarthritis and Cartilage, 18(11), 1365–1371. https://doi.org/10.1016/j.
Hawker, G., Gignac, M. A. M., Badley, E., Davis, A. M., French, M. R., Li, Y.,
… Lou, W. (2011). A longitudinal study to explain the pain-depression
link in older adults with osteoarthritis. Arthritis Care & Research, 63(10),
Hochberg, M. C., Altman, R. D., April, K. T., Benkhalti, M., Guyatt, G.,
McGowan, J., … American College of Rheumatology. (2012). American
College of Rheumatology 2012 recommendations for the use of
nonpharmacologic and pharmacologic therapies in osteoarthritis of the
hand, hip, and knee. Arthritis Care & Research, 64(4), 465–474. https://
Hochberg, M. C., Silman, A., Smolen, J., Weinblatt, M., & Weisman, M.
(2015). Rheumatology (4thed., Vols 1–2). Philapelphia, USA: Elsevier.
Hunter, D. J. (2011). Lower extremity osteoarthritis management needs a
paradigm shift. British Journal of Sports Medicine, 45(4), 283–288. https://
Hunter, D. J. (2017). Osteoarthritis management: Time to change the deck.
The Journal of Orthopaedic and Sports Physical Therapy, 47(6), 370–372.
Hunter, D. J., & Lo, G. H. (2009). The management of osteoarthritis: An
overview and call to appropriate conservative treatment. Medical Clinics,
93(1), 127–143. https://doi.org/10.1016/j.mcna.2008.07.009
Hunter, D. J., Neogi, T., & Hochberg, M. C. (2011). Quality of osteoarthritis
management and the need for reform in the US. Arthritis Care & Research,
63(1), 31–38. https://doi.org/10.1002/acr.20278
Jacobs, C. A., Vranceanu, A.-M., Thompson, K. L., & Lattermann, C.
(2018). Rapid progression of knee pain and osteoarthritis biomarkers
greatest for patients with combined obesity and depression: Data from
the osteoarthritis initiative. Cartilage, 1947603518777577. https://doi.
Jacobsen, S., & Sonne-Holm, S. (2005). Hip dysplasia: a signicant risk
factor for the development of hip osteoarthritis. A cross-sectional survey.
Rheumatology (Oxford, England), 44(2), 211–218. https://doi.org/10.1093/
Jolly, J., Bassett, S. F., O’Brien, D., Parkinson, C., & Larmer, P. J. (2017). An
exploration of the sequence and nature of treatment options available
to people living with osteoarthritis of the hip and/or knee within a New
Zealand context. New Zealand Journal of Physiotherapy, 45(2), 90–95.
Jordan, J. M., Helmick, C. G., Renner, J. B., Luta, G., Dragomir, A. D.,
Woodard, J., … Hochberg, M. C. (2007). Prevalence of knee symptoms
and radiographic and symptomatic knee osteoarthritis in African
Americans and Caucasians: The Johnston County Osteoarthritis Project.
The Journal of Rheumatology, 34(1), 172–180.
Kujala, U. M. (2009). Evidence on the effects of exercise therapy in the
treatment of chronic disease. British Journal of Sports Medicine, 43(8),
Larmer, P. J., Reay, N. D., Aubert, E. R., & Kersten, P. (2014). Systematic
review of guidelines for the physical management of osteoarthritis.
Archives of Physical Medicine and Rehabilitation, 95(2), 375–389. https://
Lingard, E. A., Katz, J. N., Wright, E. A., & Sledge, C. B. (2004). Predicting
the outcome of total knee arthroplasty. Journal of Bone and Joint Surgery
(American), 86(10), 2179.
Loew, L., Brosseau, L., Wells, G. A., Tugwell, P., Kenny, G. P., Reid, R., …
Ottawa Panel. (2012). Ottawa panel evidence-based clinical practice
guidelines for aerobic walking programs in the management of
osteoarthritis. Archives of Physical Medicine and Rehabilitation, 93(7),
McAlindon, T. E., Bannuru, R. R., Sullivan, M. C., Arden, N. K., Berenbaum,
F., Bierma-Zeinstra, S. M., … Underwood, M. (2014). OARSI guidelines for
the non-surgical management of knee osteoarthritis. Osteoarthritis and
Cartilage, 22(3), 363–388. https://doi.org/10.1016/j.joca.2014.01.003
Mease, P. J., Hanna, S., Frakes, E. P., & Altman, R. D. (2011). Pain mechanisms
in osteoarthritis: Understanding the role of central pain and current
approaches to its treatment. The Journal of Rheumatology, 38(8), 1546–
Merashly, M., & Uthman, I. (2012). Management of knee osteoarthritis: An
evidence-based review of treatment options. Le Journal Médical Libanais.
The Lebanese Medical Journal, 60(4), 237–242.
Mills, K., Hübscher, M., O’Leary, H., & Moloney, N. (2019). Current concepts
in joint pain in knee osteoarthritis. Schmerz (Berlin, Germany), 33(1),
Ministry of Health. (2018). The Mobility Action Programme. Wellington, New
Zealand: Ministry of Health. Retrieved from https://www.health.govt.nz/
National Institue for Health and Care Excellence. (2015). Osteoarthritis NICE
Guidelines (National Standard). London: National Institute of Health and
Care Excellence. Retrieved from https://www.nice.org.uk/guidance/qs87/
O’Brien, D., Bassett, S., & McNair, P. J. (2013). The effect of action and coping
plans on exercise adherence in people with osteoarthritis. New Zealand
Journal of Physiotherapy, 41(2), 49–57.
Palazzo, C., Nguyen, C., Lefevre-Colau, M.-M., Rannou, F., & Poiraudeau,
S. (2016). Risk factors and burden of osteoarthritis. Annals of Physical
and Rehabilitation Medicine, 59(3), 134–138. https://doi.org/10.1016/j.
Palmer, K. T. (2012). Occupational activities and osteoarthritis of the knee.
British Medical Bulletin, 102, 147–170. https://doi.org/10.1093/bmb/
Parsons, G. E., Godfrey, H., & Jester, R. F. (2009). Living with severe
osteoarthritis while awaiting hip and knee joint replacement surgery.
Musculoskeletal Care, 7(2), 121–135. https://doi.org/10.1002/msc.145
Phan, C. M., Link, T. M., Blumenkrantz, G., Dunn, T. C., Ries, M. D.,
Steinbach, L. S., & Majumdar, S. (2005). MR imaging ndings in the
follow-up of patients with different stages of knee osteoarthritis and the
correlation with clinical symptoms. European Radiology, 16(3), 608–618.
Pinto, D., Robertson, M. C., Abbott, J. H., Hansen, P., & Campbell, A. J.
(2013). Manual therapy, exercise therapy, or both, in addition to usual
care, for osteoarthritis of the hip or knee. 2: Economic evaluation
alongside a randomized controlled trial. Osteoarthritis and Cartilage,
21(10), 1504–1513. https://doi.org/10.1016/j.joca.2013.06.014
Piva, S. R., Susko, A. M., Khoja, S. S., Josbeno, D. A., Fitzgerald, G. K.,
& Toledo, F. G. S. (2015). Links between osteoarthritis and diabetes:
Implications for management from a physical activity perspective.
Clinics in Geriatric Medicine, 31(1), 67–87. https://doi.org/10.1016/j.
Poitras, S., Rossignol, M., Avouac, J., Avouac, B., Cedraschi, C.,
Nordin, M., … Hilliquin, P. (2010). Management recommendations
for knee osteoarthritis: how usable are they? Joint, Bone, Spine:
Revue Du Rhumatisme, 77(5), 458–465. https://doi.org/10.1016/j.
24 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
Rice, D. A., Kluger, M., McNair, P. J., Lewis, G. N., Somogyi, A. A.,
Borotkanics, R., … Walker, M. (2018). Persistent postoperative pain after
total knee arthroplasty: a prospective cohort study of potential risk factors.
British Journal of Anaesthesia, 121(4), 804–812. https://doi.org/10.1016/j.
Rosemann, T., Laux, G., Szecsenyi, J., & Grol, R. (2008). The Chronic Care
Model: congruency and predictors among primary care patients with
osteoarthritis. Quality and Safety in Health Care, 17(6), 442–446. https://
Runciman, W. B., Hunt, T. D., Hannaford, N. A., Hibbert, P. D., Westbrook,
J. I., Coiera, E. W., … Braithwaite, J. (2012). CareTrack: assessing the
appropriateness of health care delivery in Australia. The Medical Journal of
Australia, 197(2), 100–105. https://doi.org/10.5694/mja12.10510
Sharma, L., Song, J., Dunlop, D., Felson, D., Lewis, C. E., Segal, N., … Nevitt,
M. (2010). Varus and valgus alignment and incident and progressive knee
osteoarthritis. Annals of the Rheumatic Diseases, 69(11), 1940–1945.
Silverwood, V., Blagojevic-Bucknall, M., Jinks, C., Jordan, J. L., Protheroe,
J., & Jordan, K. P. (2015). Current evidence on risk factors for knee
osteoarthritis in older adults: A systematic review and meta-analysis.
Osteoarthritis and Cartilage, 23(4), 507–515. https://doi.org/10.1016/j.
Skou, S. T., Pedersen, B. K., Abbott, J. H., Patterson, B., & Barton, C. (2018).
Physical activity and exercise therapy benet more than just symptoms
and impairments in people with hip and knee ossteoarthritis. The Journal
of Orthopaedic and Sports Physical Therapy, 48(6), 439–447. https://doi.
Van Manen, M. D., Nace, J., & Mont, M. A. (2012). Management of primary
knee osteoarthritis and indications for total knee arthroplasty for general
practitioners. The Journal of the American Osteopathic Association,
Zhang, W., Moskowitz, R. W., Nuki, G., Abramson, S., Altman, R. D., Arden,
N., … Tugwell, P. (2008). OARSI recommendations for the management
of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert
consensus guidelines. Osteoarthritis and Cartilage, 16(2), 137–162. https://